DEALER APPLICATION FORM

*DO NOT fill out the form below unless you own or plan to build a service station. Instead, please fill out the Retailer Application Form.*

First Name*

Middle Name

Last Name*

Phone*

Email*

Brand*

Street Address*

City*

Province*

Do you currently own a supply agreement?*

YesNo

What is the estimated annual volume?*

Do you own the land?*

YesNo

Is the fuel equipment leased?*

YesNo

Is the signage (frames and post) owned?*

YesNo

Is there an existing convenience store or do you plan to add a convenience store?*

YesNo

Are you interested in the On The Run Dealer program?*

YesNo

Declaration*

By checking the box, the Applicant confirms that it consents, or if the Applicant is a business, that the principal(s) and/or partner(s) of the Applicant consent, to the Supplier obtaining and using personal information of the Applicant, or any principals or partners of the Applicant, as may be required from time to time in connection with the application. The Applicant also consents to the Supplier using and disclosing Applicant's information in connection with the promotion of Supplier's other products and services. The Supplier shall not sell the Applicant’s information without the Applicant’s prior written consent. The Applicant may consult the Applicant’s information held by the Supplier and, if applicable, cause same to be rectified. For further information on the Supplier’s Privacy Policy or to withdraw its consent pursuant to this paragraph, the Applicant may contact the Supplier’s Privacy Officer via www.parkland.ca or call the Supplier at 1-800-662-7177 or if the Applicant requires a copy of the Supplier’s Privacy Policy, it may forward the request in writing to the Supplier to the attention of the Supplier’s Privacy Officer at the address indicated above.

CASL Requirements*

I understand and agree with the Parkland Fuel Corporation Privacy Policy and Terms of Use and consent to receiving electronic communications, including without limitation newsletters, promotions, updates and other materials, from Parkland Fuel Corporation; and I am aware that I can unsubscribe to receiving such communications at any time. Parkland Fuel Corporation can be reached at: 1800, 240-4 Ave SW Calgary, Alberta T2P 4H4. Telephone: 403-567-2500.

Parkland Fuel Corporation Privacy Policy and Terms of Use

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